Prescription Drug Claim Form – Direct Member Reimbursement

This form is for members who have purchased medications without their ID card and need to be reimbursed. Please download and fill out the entire form, then print it out and mail or fax it to:
COA/AHC Grievances and Clinical Appeals
PO Box 17950
Denver, CO 80217

Fax: 303-755-4148

To avoid delays, please include itemized receipts with the form.